Martie Ross

1
and the Kitchen Sink2009 Medicare Physician
Fee Schedule Final Rule December 11, 2008
Donn Herring 314.613.2808 dherring_at_lathropgage.com
Martie Ross 913.451.5152 mross_at_lathropgage.com
2
2009 Final Medicare Physician Fee Schedule

• Published in the Federal Register on November 19,
  2008
• Effective January 1, 2009
• The annual IPPS, OPPS, and MPFS have become the
  Islands of Misfit Regulations

3
Payment Level Changes

• Payments under the MPFS will increase an average
  of 1.1 percent
• Reflects MIPPA adjustments otherwise payments
  would have been reduced by approximately 15
  percent
• Absent Congressional action, expect a 20 percent
  cut for 2010

4
Stark Exceptions for IncentivePayments and
Shared Savings Programs

• Incentive payments based on quality of care
• Shared savings programs gainsharing
• Proposed rule suggested Stark exception
  consistent with gainsharing advisory opinions
• Final rule CMS concluded it had not received
  sufficient information or agreement through the
  public comment process to allow it to finalize
  these exceptions
• CMS reopened the public comment process
• 55 suggested topics for comment
• Deadline is February 17

5
Application of IDTFStandards to Physician Offices

• Proposed rule Physician organizations that
  perform diagnostic testing services (other than
  mammography) be required to enroll as IDTFs
• Prohibition on sharing of space/equipment
• Qualifications of personnel
• Final Rule Defer any such new requirement for
  future consideration
• MIPPA requires accreditation of entities
  performing certain advance diagnostic testing
  procedures (MRI, CT, PET) no later than January
  1, 2012

6
Mobile Diagnostic Testing Services

• Entities that provide mobile diagnostic testing
  services must now enroll in Medicare as IDTFs.
• Such entities must bill Medicare directly for
  their diagnostic tests, except when the tests are
  furnished to hospitals under arrangement.
• Result Physicians cannot bill Medicare for
  diagnostic tests performed using equipment and
  technicians leased from a mobile entity, even
  when the tests are performed in the physicians'
  offices.
• Instead, the mobile entity will be required to
  enroll and bill Medicare directly.

7
New Anti-Markup RuleBackground

• Physicians provision of and payment for services
  (especially ancillary services) impacted by 3
  laws
• Medicare Anti-Kickback Statute criminal rule
  that prohibits the payment of remuneration in
  exchange for referrals
• Stark Law substantive rule that prohibits
  billing for DHS if furnished as a result of
  prohibited referral
• Purchased Diagnostics Rule substantive rule
  that limits how much a physician can bill
  Medicare for the technical component of a
  diagnostic test purchased from another provider

8
Original Purchased Diagnostic Rule

• Applied to
• The technical component of diagnostic tests
  billed by physician or other supplier including,
  without limitation, x-ray, EKGs, EEGs, cardiac
  monitoring, ultrasound, and the technical
  component of physician pathology services
• If such technical component was
• Purchased outright from an outside supplier
• Provided through staff and equipment leased from
  an outside supplier

9
Original Purchased Diagnostic Rule

• Payment limited to lesser of
• Fee schedule amount if the outside supplier
  billed directly
• Physicians actual charge
• Outside suppliers net
• Interpreted as actual charge

10
Purchased Diagnostics Cheat Sheet
11
Anti Mark-Up RuleIntended To Go Into Effect
January 1, 2008

• Applies to
• The technical component or professional component
  of a diagnostic test billed by a physician or
  other supplier
• If that diagnostic test was
• Ordered by the physician or other supplier (or a
  related party) and
• Purchased from an outside supplier or
• Performed at a site other than an office where
  the physician or other supplier provides
  substantially the full range of patient care
  services that the physician or other supplier
  regularly provides

12
Anti Mark-Up Rule Intended To Go Into Effect
January 1, 2008

• Payment limited to lesser of
• Fee schedule amount if outside supplier billed
  directly
• Billing physician or other suppliers actual
  charge
• The net charge
• Defined as actual charge for a purchased test
  and cost for tests performed at an
  inappropriate location (excluding overhead costs
  like rent)

13
Anti Mark-UpProposed 2008Cheat Sheet
14
Anti Mark-Up RuleEffective January 1, 2009

• Applies to
• The technical component or professional component
  of a diagnostic test billed by a physician or
  other supplier
• If that test was
• Ordered by such physician or other supplier (or a
  related party) and
• Performed by a physician who does not share a
  practice with the billing physician or other
  supplier

15
Anti Mark-Up RuleEffective January 1, 2009

• A performing physician shares a practice with the
  billing physician or other supplier if
• He or she furnishes substantially all (i.e., at
  least 75) of his or her professional services
  through such billing physician or other supplier
  or
• He or she is an owner, employee, or independent
  contractor of the billing physician or other
  supplier and the professional component/technical
  component is performed in the office of the
  billing physician or other supplier.

16
Anti Mark-Up RuleEffective January 1, 2009

• For purposes of The Anti Mark-Up Rule,
• The office of the billing physician or other
  supplier is any medical office space in which
  the ordering physician or other supplier
  regularly furnishes the full range of patient
  care services the order physician or other
  supplier provides generally.
• The physician who performs the technical
  component of a diagnostic test is the physician
  who supervises the diagnostic test.
• The technical component of a diagnostic test is
  performed in the location in which the test takes
  place and the location at which the supervising
  physician is located.

17
Anti Mark-Up2009 Cheat Sheet
18
Anti Mark-Up RuleEffective January 1, 2009

• Payment limited to lesser of
• Fee schedule amount if performing physician or
  other supplier billed directly
• Billing physicians or other suppliers actual
  charge
• The net charge
• Defined as actual charge for purchased tests
  and cost for test performed at an inappropriate
  location (excluding overhead costs like rent).

19
Coverage for Telehealth Services

• Proposed rule Include diabetes self-management
  training, critical care services, and follow-up
  inpatient telehealth consultations as
  Medicare-reimbursed telehealth services
• Final rule follow-up inpatient telehealth
  consultations
• Additional originating cites hospital-based
  renal dialysis facilities, skilled nursing
  facilities, and community mental health centers

20
Multiple Procedure Payment Reductions

• When two or more listed procedures are provided
  to the same patient in a single session, the
  technical component of the highest priced
  procedures is paid at 100 percent and the
  technical component of subsequent procedures is
  paid at 75 percent
• For 2009, CMS will add 10 codes to this list,
  including certain cardiac MRIs, breast and chest
  examinations, and certain brain, neck, and head
  scans
• Reduction maintained at 25 percent, not proposed
  50 percent

21
Physician and Non-PhysicianPractitioner
Enrollment

• Current rule newly enrolled practitioner may
  submit claims for services furnished up to 27
  months prior to the date they received Medicare
  billing privileges.
• New rule retrospective billing limited to 30
  days, provided certain conditions are met

22
Physician and Non-PhysicianPractitioner
Enrollment

• Current rule Practitioner has 90 days to notify
  CMS of final adverse action (e.g., felony,
  license suspension, or exclusion) or change in
  practice locations
• New rule Notice must be provided within 30 days
• Failure to do so will result in an overpayment
  based on the date of the final adverse action or
  the change of location
• Rule applies to group practices as well as
  individual practitioners organizations as well as
  practitioners.

23
Changes to AmbulanceBeneficiary Signature
Requirements

• General rule To submit a claim for Medicare
  payment, ambulance service must obtain signature
  of beneficiary/ authorized representative,
  subject to certain exceptions
• Exception created in 2008 PFS May submit claim
  for emergency transport without signature if no
  other individual is available and authorized to
  sign for an emergency ambulance transport claim
  on behalf of a beneficiary who is physically or
  mentally incapable of signing
• 2009 PFS extends this exception to non-emergency
  transports 

24
Prohibition Concerning Providers of Sleep Tests

• Proposed rule Supplier of a continuous positive
  air pressure (CPAP) device cannot bill for device
  if that supplier, or its affiliate, is directly
  or indirectly the provider of the sleep test used
  to diagnose the beneficiary with obstructive
  sleep apnea
• Final rule Exception for attended
  facility-based sleep tests

25
Speech-Language Pathologists in Private Practice

• Beginning July 1, 2009, speech-language
  pathologists may bill Medicare and receive direct
  payment for Medicare-covered outpatient
  speech-language pathology services furnished in
  private practice.
• Rules are similar to those for physical
  therapists and occupational therapists in private
  practice.
• The supplier possesses a state license or other
  necessary legal authority to provide SLP
  services.
• The services are provided in one of the specified
  private practice office settings.
• Services are provided to patients of the practice
  and for whom the practice collects the fees for
  the services furnished.

26
Maintaining Orderingand Referring Documentation

• Providers and suppliers to maintain written
  documentation including the NPI of the ordering
  and referring practitioner for seven years from
  the date of service.
• Failure to maintain such documentation may result
  in loss of provider number.

27
E-Prescribing Incentive Program

• MIPPA mandated incentive program for eligible
  professionals who are successful electronic
  prescribers.
• Effective for calendar year 2009, a successful
  electronic prescriber is eligible for an annual
  incentive payment equal to 2 of estimated Part B
  allowed charges for the year.
• Carrot followed by a stick
• Bonus payment reduces over time
• By 2014, there will be a 2 reduction in payment
  for Part B claims submitted by eligible
  professionals who are not successful electronic
  prescribers (subject to certain exceptions).

28
Successful Electronic Prescriber

• For 2009, in order to be considered a successful
  electronic prescriber, a prescriber must meet
  certain requirements with respect to their Part B
  claims submissions. These include
• The prescriber must report the required data
  elements of the electronic prescribing quality
  measures(s) on at least 50 of the applicable
  Part B encounters where such reporting is
  permitted based on the CPT code reported
• Total estimated Part B allowed professional
  charges for which a prescriber is required to
  report electronic prescribing data elements must
  represent at least 10 percent of prescribers
  total Part B allowed charges

29
Qualified Electronic Prescribing System

• Generate a medication list
• Allow eligible professionals to select
  medications, print prescriptions, transmit
  prescriptions electronically and conduct safety
  checks (including automated prompts that offer
  information on the drug being prescribed,
  potential inappropriate dose or problems withhow
  the drug comes in contact with the patients body
  (the routeof administration), drug-to-drug
  interactions, allergy concerns, and
  warnings/cautions)
• Provide information on lower-cost alternatives
• Provide information on formulary or tiered
  formulary medications, patient eligibility, and
  authorization requirements that are received
  electronically from the patients drug plan.

30
Method of Payment

• Determination of prescribers who are successful
  electronic prescribers for 2009 will occur at the
  individual professional level, based on NPI, and
  payment will be made to the practice represented
  by the tax identification number associated with
  a professional's NPI number.

31
Physician Quality Reporting Initiative

• MIPPA extended program indefinitely
• Eligible for 2 bonus payment
• Additional measures and new measurement groups

32
(No Transcript)
33
Martie Ross
Donn Herring